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 ORIGINAL ARTICLE

Acta Orthop Traumatol Turc 2012;46(5):346-352

doi:10.3944/AOTT.2012.2787

Efficacy of sonographically guided

intra-flexoral sheath corticosteroid injection
in the treatment of trigger thumb

Mohsen MARDANI-KIVI1, Farivar Abdullahzadeh LAHIJI2, Ali Babaei JANDAGHI3,

Khashayar SAHEB-EKHTIARI4, Keyvan HASHEMI-MOTLAGH4
1
Department of Orthopedics, Guilan University of Medical Sciences, Rasht, Iran;
2
Department of Orthopedics, Shahid Beheshti University of Medical Sciences, Tehran, Iran;
3
Department of Radiology, Guilan University of Medical Sciences, Rasht, Iran;
4
Orthopedics Research Center, Guilan University of Medical Sciences, Rasht, Iran

Objective: The aim of this study was to determine the efficacy of sonographically guided intra-flexo-
ral sheath corticosteroid injection in the treatment of trigger thumb.
Methods: This study included 112 trigger thumbs of 104 patients (7 males, 97 females; mean age:
52.11 years) studied prospectively from 2009 to 2011. All patients experienced pain, tenderness, dis-
comfort and/or triggering with flexion/extension of the thumb and palpable nodules at the level of the
A1 pulley. Ultrasonographically guided corticosteroid injection was performed on all affected thumbs.
Thumb improvement was evaluated using the Quinnell grading system and patients were followed up
for one year.
Results: All 112 thumbs received one ultrasonographically guided corticosteroid injection. Fifteen
thumbs (13.4%) needed re-injection and/or surgery during their one year follow-up. Eight (53.3%) of
these 15 cases, had a pre-treatment Quinnell Grade of 4, six (40%) thumbs were Grade 3 and one
(6.7%) was Grade 2. Twelve were re-injected, two underwent surgery without re-injection and one
underwent surgery after showing no improvement following re-injection. There was a significant
reduction in the post-injection Quinnell grade (p<0.0001). One year after the initial injection, 108
thumbs (96.4%) were completely symptom-free.
Conclusion: Sonographically guided intra-flexoral sheath corticosteroid injection is an effective
method in the treatment of trigger thumb and reduces the need for surgery.
Key words: Corticosteroid injection; tenosynovitis; therapeutic; trigger thumb; ultrasound.

Trigger finger/thumb is one of the most prevalent
causes of hand disability and is a common cause of
referral to orthopedic clinics.[1-3] It is more common
among women,[1,3-6] with the thumb having the highest
involvement.[1,6,7] Symptoms include snapping, locking,
rigidity, a click, difficulty in opening the flexed finger
and pain caused by inflammation and progressive
hypertrophy of the finger or thumb flexor tendon
sheath at the level of the A1 pulley.[8-13] The first line of
treatment are conservative methods, such as finger

Correspondence: Mohsen Mardani-Kivi, MD. Guilan University of Medical Sciences,

Namjoo Avenue, Rasht, Iran, PO Box: 4193713191.
Tel: +98-131 - 323 98 42 e-mail: dr_mohsen_mardani@yahoo.com Available online at
Submitted: December 3, 2011 Accepted: April 4, 2012 www.aott.org.tr
doi:10.3944/AOTT.2012.2787
©2012 Turkish Association of Orthopaedics and Traumatology QR (Quick Response) Code:
Mardani-Kivi et al. Efficacy of ultrasound-guided intra-flexoral sheath corticosteroid injection in trigger thumb
rests with or without the use of a splint and a local cor-
ticosteroid injection.[1,14-16] Surgical treatments are inva-
sive and have potential complications. Although good
results with surgical treatment are possible in children
over one year of age,[17] surgery is only indicated if non-
surgical treatments fails in adults.[7,14,18]
Intra-flexoral corticosteroid injection is the most
common non-surgical treatment with a reported suc-
cess rate between 38 and 93% for the treatment of trig-
ger thumb.[1,6,19,20] Recently, studies have questioned the
accuracy and precision of intra-sheath blind corticos-
teroid injection and its effect on the treatment success
rate.[1] A recent study explored the intra-sheath delivery
of corticosteroids using a blind injection of methylene
blue and corticosteroid into the sheath before open
surgery in the treatment of trigger thumb. They
observed that the contrast medium was successfully
injected into the flexoral sheath in only half of the
blind injections and was clinically manifested as an
increase in the duration of symptoms in this sub-group
of patients.[21] In addition, reports have been issued
about hazardous consequences of blind injection of
corticosteroids.[22,23] Lee et al. performed a study com-
paring 20 ultrasound-guided injections and 20 blind
injections and reported successful intra-sheath injec-
tion in 70% of the group with ultrasound-guided injec-
tions and only in 15% in the group receiving blind
injections.[24] Therefore, the aim of this study was to
study the therapeutic outcomes and complications of
ultrasound-guided intra-flexoral sheath injection.
Patients and methods
This descriptive, prospective study reviewed all
patients referred to our orthopedic clinic for trigger
thumb between March 2009 and March 2011.
Inclusion criteria were pain and tenderness at the posi-
tion of A1 pulley, pain and discomfort when flexing
and extending the finger, nodule palpation, presence of
a clicking sound at the time of flexion or extension of
the thumb, snapping or locking of finger, and the exis-
tence of a trigger state. Patients with any kind of con-
comitant local tenosynovitis such as De Quervain’s dis-
Table 2. The frequency of concomitant medical conditions in the population of the patients of this study.
Type of
synchronous Number of
disease patients*
Diabetes mellitus 20
Hypothyroidism 7 25%
Rheumatoid arthritis 3 10.7%
*One patient was simultaneously afflicted with diabetes mellitus and rheumatoid arthritis and one patient had diabetes mellitus and
hypothyroid simultaneously.
347
ease, carpal tunnel syndrome and Dupuytren’s con-
tracture, involvement of other fingers, clinical doubt as
to the true nature of the symptoms or any history of
local corticosteroid injection were excluded.
Additionally, patients undergoing ultrasound-guided
intra-flexoral sheath injection treatment in the first
three months were excluded. One hundred and twelve
thumbs of 104 patients (7 men, 97 women; mean age:
52.11±7.63 years; range: 26 to 69 years) were included
in the study (Fig. 1).
The affected side was right in 64 patients, left in 32
and bilateral in 8. Trigger thumb was seen in the dom-
inant hand in 89 of 112 thumbs (79.5%) and in the
non-dominant hand in 23 (20.5%). Patients were grad-
ed according to Quinnell’s grading classification
(Table 1). Of the 104 patients, 28 (26.9%) had con-
comitant medical conditions (Table 2). Symptoms
were present for less than six months (<6 months
group) in 107 thumbs (95.5%) and more than 6
months (>6 month group) in 5 thumbs (4.5%).
Table 1. Quinnell's grading system.
Grade Explanation
1 Without trigger state, uneven finger movement or slight
crepitation
2 Trigger state, finger snapping that is corrected actively
3 Trigger state, finger snapping that is corrected passively
4 Finger locking, uncorrectable
Previous studies have showed increased success rates
with the insertion of a 25-gauge needle in a proximal to
distal direction at an angle of 30-45° angle from the volar
side into the anatomic position of the A1 pulley.[4,21,25] We
performed the same procedure using 1 ml of 40 mg/ml
methyl prednisolone acetate and 0.5 ml of 2% lidocaine
hydrochloride in all patients. All examinations, diagno-
sis, injections, investigation of therapeutic outcomes and
re-injections or operations, if needed, were performed
by the corresponding author. Ultrasound guidance was
Frequency in persons
having concomitant Frequency in
medical conditions all patients
71.4% 19.2%
6.7%
2.9%
348
Fig. 1. Setting the probe to find the tendon in axial view. [Color
figure can be viewed in the online issue, which is available
at www.aott.org.tr]
performed using a 14 MHz linear probe (Ultrasonix,
Touch model, ver. 5.5.4). First, the tendon was detect-
ed through an axial scan of the proximal phalanx (Fig.
2) and the probe was rotated until a fibrillary echo pat-
tern was visualized and adjusted in the screen center.
Next, the probe was moved proximally to the first MCP
joint and the first annular pulley appeared (Fig. 3). The
Fig. 3. Inserting the needle at 30-45° angle.
[Color figure can be viewed in the online issue, which is
available at www.aott.org.tr]
Fig. 5. Longitudinal view of tendon after corticosteroid injection
(Arrows: confluence of liquid inside sheath around tendon,
star: the first metacarpophalangeal joint).
Acta Orthop Traumatol Turc
Fig. 2. Rotating the probe to find the tendon in longitudinal view.
[Color figure can be viewed in the online issue, which is
available at www.aott.org.tr]
needle was inserted into the space between the A1 pul-
ley and flexor pollicis longus at a 30 to 45° angle ori-
ented proximal to distal and the solution injected (Fig.
4). Distension of the tendon sheath and the resultant
fluid wave inside from the finger tip to the injection
site were confirmed during the injection process (Figs.
5-7).
Fig. 4. Longitudinal view of needle's entrance (Hollow arrows:
needle, solid arrows: tendon, star: the first metacarpopha-
langeal joint).
Fig. 6. Axial view of the tendon after corticosteroid injection
(Arrows: fluid collection inside sheath around tendon).
Mardani-Kivi et al. Efficacy of ultrasound-guided intra-flexoral sheath corticosteroid injection in trigger thumb 349

60%

50%
50%

40%
33.7%
Frequency

30%

20%
13.5%

10%
2.9%
0%
0%
20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60-69 yrs

Age

Fig. 7. Age distribution of the patients.

Patients were followed-up at 3 and 6 weeks, 3 and 6
months and 1 year after the first injection. Of the orig-
inal 117 patients, 13 were excluded from the study
because of failed follow-up. The Quinnell’s criterion
was applied to evaluate improvements during follow-
up. Patients were observed for 6 weeks and further
treatment (re-injection or surgery) was suggested to
patients and performed depending on patient prefer-
ence. In addition, patients who were still symptomatic
after 2 injections became candidates for open surgery.
Collected data was saved separately into two thera-
peutic groups and was statistically analyzed using SPSS
software package for Windows v.19.0 (SPSS Inc.,
Chicago, IL, USA). After summarizing the characteris-
tics of both groups with descriptive statistics, response
variables were evaluated according to the
Kolmogorov-Smirnov test and it was shown that none
had a normal distribution. The Mann-Whitney U test
was used in order to compare these variables of both
groups and the chi-squared test to compare the differ-
ences of qualitative parameters between groups. To
analyze the trend of Quinnell’s grade changes, repeat-
ed measure analysis test through Mauchley’s test of
sphericity was employed, and to evaluate the value of
these changes, analysis of variance (ANOVA) was per-
formed. In all statistical tests, the p value was set at
0.05.
Results
Symptoms were completely ameliorated after one
injection in 86.6% of thumbs. These patients had no
relapse. At the one year follow-up, 15 thumbs (13.4%)
needed reinjection and/or surgery. Of these 15
thumbs, 12 (80%) were re-injected, 2 (13.3%) under-
went surgery without re-injection, and one (6.7%) was
re-injected and underwent subsequent surgery. No
thumb was injected more than two times. Of the 13
reinjection cases, only one case (7.7%) needed surgery.
After one year (6th visit), 109 thumbs (97.3%) were
symptom-free and only one thumb was at Quinnell’s

Table 3. Frequency distribution and the mean of Quinnell's grade of fingers in performed visits.

Without Mean±SD
Turn of visit symptom Grade 1 Grade 2 Grade 3 Grade 4 of grade

Number (%) Number (%) Number (%) Number (%) Number (%)

First 0 (0) 3 (2.7) 56 (50) 33 (29.5) 20 (17.9) 2.61±0.81

Second 105 (93.8) 5 (5.4) 1 (0.9) 0 (0) 1 (0.9) 0.10±0.46
Third 102 (91.1) 7 (6.3) 1 (0.9) 1 (0.9) 1 (0.9) 0.14±0.55
Fourth 103 (92) 7 (6.3) 1 (0.9) 1 (0.9) 0 (0) 0.11±0.41
Fifth 106 (94.6) 3 (2.7) 3 (2.7) 0 (0) 0 (0) 0.08±0.36
Sixth 111 (99.1) 1 (0.9) 0 (0) 0 (0) 0 (0) 0.01±0.09
350 Acta Orthop Traumatol Turc

3.0 4 Time
Less than 6mth
More than 6mth
2.5
Quinnell’s grade (Mean)

Quinnell’s grade (Mean)

3
2.0

1.5 2

1.0
1
.5

.0 0

1st 2nd 3rd 4th 5th 6th 1st 2nd 3rd 4th 5th 6th
Visits Visits

Fig. 8. Overall Quinnell's grade in visits. Fig. 9. Quinnell's grade in two groups of less and more than 6
months.

Grade 1. Due to this patient’s unwillingness, reinjec-
tion or surgery was not performed.
Quinnell’s grading for thumbs from the first to
sixth visits is shown in Table 3. Statistical analysis
revealed that the trend and value of variations of
Quinnell’s grade are statistically significant for all
thumbs (p<0.0001) (Fig. 8). In addition, trend and
value of variations of Quinnell’s grade was statistically
significant between the over and under 6 month symp-
tom groups (p<0.0001) (Fig. 9). There was no signifi-
cant difference in trend and value of variations of the
Quinnell’s grade between diabetic and non-diabetic
patients (p=0.85 and p=0.63, respectively). Quinnell’s
grades of these two groups are given in Fig. 10.
Complications were not seen in any patient.
Discussion
Quinnell’s grade (Mean)
of sonographic guidance. The inaccuracy associated
with blind injection appears to be responsible for the
decrease in success rates seen in intra-sheath delivery
of corticosteroids.[21,24]
The relationship between the existence of one or
more concomitant medical conditions and the efficacy
of corticosteroid injection has also been scruti-
nized.[6,14,19,27-29] Many authors, including Blythe and Ross,
regarded trigger thumb as a part of what they called
“diabetic hand syndrome”.[28] Since there were a limited
number of patients with both hypothyroidism (6.7%)
and rheumatoid arthritis (2.9%) in this study, we chose
3
Non-Diabetics
Diabetics
2.5

The effect of corticosteroid injections in the treatment

of stenosing tenosynovitis is a contentious issue in 2.0

orthopedics. Despite studies for more than a quarter

1.5
century, the role of corticosteroid injections into the
flexor tendon’s sheath and the importance of intra-
1.0
sheath delivery in the treatment of trigger finger and
thumb has been questioned.[1,19,21,26] In the present study,
.5
109 of 112 thumbs (97.3%) were completely symptom-
free one year post-injection. This rate is higher than
.0
the reported success rates of 38 to 93% in previous
studies.[1,16,19,20] Those studies with a varying range of 1st 2nd 3rd 4th 5th 6th

success rates relied on blind injection for the corticos- Visits

teroid delivery, while those with higher success rates, Fig. 10. Quinnell's grade in two groups of diabetic and non-diabet-
including the present study, were attained with the aid ic patients.
Mardani-Kivi et al. Efficacy of ultrasound-guided intra-flexoral sheath corticosteroid injection in trigger thumb
to discuss diabetic patients, as it is very common in our
patient population. In several previous studies,[2,19,29] dia-
betic patients showed less therapeutic response than
non-diabetic individuals and required surgical treatment
more often. In a study of 54 diabetic patients with 121
trigger thumbs over a 3 year follow-up, Griggs et al.[27]
reported that symptoms were completely ameliorated in
34 fingers (28%) after the first injection, and this num-
ber increased by an additional 27 fingers (22%) after the
second and third injections. Sixty fingers (50%)
improved slightly and required surgery to release the A1
pulley. In the present study, although a higher percent-
age of diabetic thumbs opposed to non-diabetic thumbs
(30.8% and 18.2%, respectively) required reinjection,
this difference was not statistically significant (p=0.28).
This indicates that diabetic patients benefit from ultra-
sound-guided intra-flexoral injection as much as non-
diabetic patients.
Limitations of sonographically guided intra-flexo-
ral injection are the limited availability of sonography
and the need for skillful radiologists for ultrasound
guidance, which cause significantly more costs com-
pared to the blind method. However, the reduction in
the need for surgery and the remarkable increase in the
speed and rate of symptom amelioration results in a
reduction in health care costs and the financial burden
arising from patients’ disability.
This study was conducted on the thumb only. With
the exception of a limited number of case studies,[2]
most studies have been conducted on trigger fingers
(thumbs and fingers) and the fact that this study is lim-
ited to the thumb makes it difficult to compare and
generalize its results to other fingers. On the other
hand, the present study included a large sample volume
of thumbs that is rare. Further studies that consider the
efficacy of the same method in other fingers with a
larger volume of samples are recommended.
In conclusion, sonographically guided corticos-
teroid injection into the sheath of the flexor tendon of
the thumb appears to be a highly useful in the treat-
ment of trigger thumb and decreases the need for sur-
gery, especially in patients who with a symptom dura-
tion of less than six months.
Conflicts of Interest: No conflicts declared.
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